EITC Health Professions
Packet Application
For School Year 2009-2010

Thank you for your interest in Eastern Idaho Technical College’s Health Professions programs.

If you have any further questions please feel free to contact Shelley Wetzel at 524-3000 ext. 3437 or swetzel@eitc.edu

Before we provide you with an application packet for one of our Health Professions programs, we need the following information from you:

* All information is required! Do not leave blank! (If you need to, simply answer No or enter N/A)

1. *Are you currently enrolled at EITC?
Yes No
2. *Which program are you enrolled in?
3. *Have you met with a Faculty Advisor from your program of study?
Yes No
4. *Who?

5. *Are you currently taking health-related pre-requisite courses from another institution for your chosen program?
Yes No
6. *Where are you taking your pre-requisite courses?
7. *Have you contacted Steve Albiston , Dean of Students to review your non-EITC transcripts?
Yes No

8. *Are you requesting an application packet for next year's acceptance?
      Yes   No
9. *Are you requesting an application packet for information only?
      Yes   No
10. *Which application packet are you requesting?
      Registered Nurse   Practical Nursing   Surgical Technology   Medical Assisting/Medical Office Support

11. *First Name
12. *LastName
13. *Mailing Address
14. *City
15. *State
16. *Zip
17. *Home Phone
18. *Cell Phone
19. *Work Phone
20. *Email Address

21. I understand that failure to provide complete information will result in my file being incomplete and may cause me to miss the deadline. Entering my full legal name in this box serves as my signature and promises that the above information is correct.

EITC Health Professions Packet Application For School Year 2009-2010

EITC Health Professions
Packet Application
For School Year 2009-2010